G.I.R.L.S. ROCK SACRAMENTO

Camper's Full Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent/Guardian's Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

Address *

Camper must reside within the Del Paso Heights community.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

Adult other than parent/guardian listed above

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Which of the following best represents your camper's racial or ethnic heritage? Choose all that apply. *

Native American or Alaskan Native

Black, Afro-Caribbean, or African American

Latinx or Hispanic American

Asian or Pacific Islander

South Asian or Indian American

Middle Eastern or Arab American

Non-Hispanic White or Euro-American

Other

With which of the following does your camper identify? *

Please check all that apply. We collect this information for grant reporting purposes. Thank you!

LGBTQ2S+

Female

Male

Transgender

Immigrant

Refugee

Person with a Disability

Justice Impacted Person

Other